Medigap. Outline of Coverage for Plans A, C, D, F, G and N

Medigap Outline of Coverage for Plans A, C, D, F, G and N

Contents About Priority Health... 3 Choosing a plan is easy... 4 Coverage that meets your needs... 5 Learn more about your choices... 12 Understanding your premiums... 13 How to apply... 20 2 Call us toll-free 866.562.5921, seven days a week from 8 a.m. 8 p.m. TTY users should call 711.

A healthier approach to health care Priority Health is dedicated to improving the health and lives of our members. That means we do what it takes to make sure you get the quality care you need, when you need it. We re committed to making it easier for you to understand your coverage options and how to get the most from your health plan. You can depend on Priority Health for excellent coverage no matter which plan you choose. Service you can count on Local, friendly customer service available 7 days a week to answer questions Based in Michigan, with more than 30 years of experience improving member health 97% of our Medicare members would recommend us to their friends and family* * July 2014 Priority Health Medicare research report conducted by Kiekover Marketing.

Choosing a plan is easy We have what you re looking for in a Medigap plan. With a Priority Health Medigap plan, you ll be protected from large medical bills with reliable, easy-to-understand coverage. The coverage you need If you have Original Medicare, you re covered for many hospital and medical expenses. But you may be surprised how quickly your deductibles, copays and coinsurance can add up. Can you afford the coverage gaps in Original Medicare? For example, in 2017, if you go to the hospital, you will need to pay a $1,316 deductible right away, before your coverage begins. If you need to be in the hospital for a long time, you ll pay $329 per day for days 61 90, then $658 each day after 90 days. To avoid paying for these costly coverage gaps, consider a Priority Health Medigap plan to help with these expenses. Questions about our plans? Call us toll-free at 866.562.5921, TTY users should call 711 Visit prioritymedicare.com Contact your local agent Priority Health offers Medicare Supplement Plan A, Plan C, Plan D, Plan F, Plan G and Plan N. The federal government standardizes all of the plans. See page 6 for more complete information about each plan. 4 Call us toll-free 866.562.5921, seven days a week from 8 a.m. 8 p.m. TTY users should call 711.

Coverage that meets your needs Live with confidence because you know you re covered. The freedom to go to any doctor or hospital who accepts Medicare anywhere No referral needed to see a specialist No hidden fees no application or association fee on top of your monthly premium A guarantee that your rate can only change once every 12 months Earn cash back to support your healthy lifestyle with the Benefit mobile app Online health risk appraisal and healthy living resources Virtually no claims paperwork for you **Plans C, D, F, G and N Worldwide emergency coverage** Enjoy easy renewal Once you ve enrolled in a Priority Health Medigap plan, the rest is easy. Your claims are processed automatically, and we ll pay your providers directly. Your coverage will automatically be renewed each year as long as you pay your premiums. prioritymedicare.com 5

Choose the benefits that are most important to you Medicare Supplement insurance can be sold in only 11 standard plans, one of which is a high deductible plan. The following chart shows the benefits included in each plan. Every insurer must offer Plan A and Plan C. Some plans may not be available in your state. Priority Health offers Plans A, C, D, F, G and N. Basic benefits included in all Medigap plans: Hospitalization: Part A copayments plus coverage for 365 additional days after Medicare benefits end Medical expenses: Part B coinsurance (20% of Medicare-approved expenses) or copays. Plans K, L and N require you to pay a portion of the Part B coinsurance or copayments Medicare preventive care: Part B coinsurance (20% of Medicareapproved expenses) when applicable Blood: First three pints of blood each year (Original Medicare covers additional pints) Hospice: Part A coinsurance for inpatient respite care and copays for outpatient prescription drugs Additional benefits available in select Medigap plans: Hospitalization: Part A deductible per Benefit Period ($1,316 in 2017) Skilled nursing facility care: Part A daily copayments for days 21 through 100 of each Benefit Period Medical expenses: Part B deductible per calendar year ($183 in 2017) Part B excess charges: All costs above Medicare-approved amounts Foreign travel emergency care: 80% of Medicare-eligible expenses for emergency care services received outside the U.S. after you meet a foreign travel deductible 6 Call us toll-free 866.562.5921, seven days a week from 8 a.m. 8 p.m. TTY users should call 711.

Benefits included in all Medigap plans Benefits Inpatient hospital services Medicare Part A daily copayments plus an additional 365 days of coverage after Medicare benefits end Hospice care Medicare Part A coinsurance and copayments Medicare preventive care Medicare Part B coinsurance when applicable Medical expenses Medicare Part B coinsurance Plans A B C D F F* G K** L** M N 50% 75% 50% 75% 100% except up to a $20 office visit copayment and up to a $50 emergency visit copayment Blood 50% 75% First 3 pints under Medicare Parts A and B Skilled nursing facility care 50% 75% Medicare Part A daily copayments Medicare Part A deductible 50% 75% 50% Medicare Part B deductible Medicare Part B excess charges Foreign travel Emergency services 80% 80% 80% 80% 80% 80% 80% Out-of-pocket annual limit*** $5,120 $2,560 All benefits listed are covered at 100% unless the chart indicates otherwise. The Medigap plan covers copayments/coinsurances only after the deductible is met unless the plan covers it. *Plan F has an option called a high deductible plan F. This high deductible plan pays the same benefits as plan F after you have paid a calendar year deductible of $2,000. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed $2000. Out-of pocket expenses for this deductible are expenses that would ordinarily be paid by the plan. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan s separate foreign travel emergency deductible. **Plans K and L include the same basic benefits as the other Medigap plans, but the cost-sharing you pay for the basic benefits is at different levels. Once you reach the out-of-pocket annual limit, the plan pays 100% of the Medicare copayments, coinsurance and deductibles for the rest of the calendar year. The out-of-pocket annual limit does not include charges from your provider that exceed Medicare-approved amounts, called excess charges. You will be responsible for paying excess charges. ***The out-of-pocket annual limit will increase each year for inflation. prioritymedicare.com 7

Medigap plans A, C, D, F, G and N All dollar amounts shown are the 2017 Original Medicare numbers. The benefits and costs shown below are for plans effective on or after January 1, 2017. Plan A Plan C Plan D Services Original Medicare pays Plan pays You pay Plan pays You pay Plan pays You pay p Medicare (Part A) hospital services per benefit period Hospitalization 1 Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,316 Nothing $1,316 (Part A deductible) $1,316 (Part A deductible) Nothing $1,316 (Part A deductible) 61st thru 90th day All but $329 a day $329 a day Nothing $329 a day Nothing $329 a day Nothing 91st day and after (while using 60 lifetime reserve days) All but $658 a day $658 a day Nothing $658 a day Nothing $658 a day Nothing Once lifetime reserve days are used; additional 365 days Nothing 100% of Medicare eligible expenses Nothing 2 100% of Medicare eligible expenses Nothing 2 100% of Medicare eligible expenses Beyond the additional 365 days Nothing Nothing All costs Nothing All costs Nothing All costs Skilled nursing facility care 1 You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days 100% Nothing 21st thru 100th day All but $164.50 a day Nothing Up to $164.50 a day Up to $164.50 a day Nothing Up to $164.50 a day Nothing 101st day and after Nothing Nothing All costs Nothing All costs Nothing All costs Blood First 3 pints Nothing 3 pints Nothing 3 pints Nothing 3 pints Nothing Additional amounts 100% Nothing Hospice care Available as long as your doctor certifies you are terminally ill and you elect to receive these services Hospice care 100% Nothing Outpatient prescription drugs All but $5 per prescription $5 per prescription Nothing $5 per prescription Nothing $5 per prescription Nothing Inpatient respite care 95% 5% of Medicare eligible expenses Nothing 5% of Medicare eligible expenses Nothing 5% of Medicare eligible expenses Medicare (Part B) medical services per calendar year Medical expenses In or out of the hospital and outpatient hospital treatment, such as physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. First $183 of Medicare approved amounts (Part B deductible 3 ) Nothing Nothing $183 $183 Nothing Nothing $183 Nothing Nothing 2 Nothing Remainder of Medicare approved amounts (after deductible is met) Part B excess charges (above Medicare approved amounts) 80% 20% Nothing 20% Nothing 20% Nothing Nothing Nothing All costs Nothing All costs Nothing All costs 8 Call us toll-free 866.562.5921, seven days a week from 8 a.m. 8 p.m. TTY users should call 711.

Plan F Plan G Plan N Services Original Medicare pays Plan pays You pay Plan pays You pay Plan pays You pay Medicare (Part A) hospital services per benefit period Hospitalization 1 Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,316 $1,316 (Part A deductible) Nothing $1,316 (Part A deductible) Nothing $1,316 (Part A deductible) Nothing 61st thru 90th day All but $329 a day $329 a day Nothing $329 a day Nothing $329 a day Nothing 91st day and after (while using 60 lifetime reserve days) All but $658 a day $658 a day Nothing $658 a day Nothing $658 a day Nothing Once lifetime reserve days are used; additional 365 days Nothing 100% of Medicare eligible expenses Nothing 2 100% of Medicare eligible expenses Nothing 2 100% of Medicare eligible expenses Beyond the additional 365 days Nothing Nothing All costs Nothing All costs Nothing All costs Skilled nursing facility care 1 You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days 100% Nothing 21st thru 100th day All but $164.50 a day Up to $164.50 a day Nothing Up to $164.50 a day Nothing Up to $164.50 a day Nothing 101st day and after Nothing Nothing All costs Nothing All costs Nothing All costs Blood First 3 pints Nothing 3 pints Nothing 3 pints Nothing 3 pints Nothing Additional amounts 100% Nothing Hospice care Available as long as your doctor certifies you are terminally ill and you elect to receive these services Hospice care 100% Nothing Outpatient prescription drugs All but $5 per prescription $5 per prescription Nothing $5 per prescription Nothing $5 per prescription Nothing Inpatient respite care 95% 5% of Medicare eligible expenses Nothing 5% of Medicare eligible expenses Nothing 5% of Medicare eligible expenses Medicare (Part B) medical services per calendar year Medical expenses In or out of the hospital and outpatient hospital treatment, such as physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. First $183 of Medicare approved amounts (Part B deductible 3 ) Nothing $183 Nothing Nothing $183 Nothing $183 Nothing 2 Nothing Remainder of Medicare approved amounts (after deductible is met) 80% 20% Nothing 20% Nothing 20% except up to a $20 office visit and up to a $50 emergency visit copay Up to $20 per office visit and up to $50 per emergency room visit. 4 Part B excess charges (above Medicare approved amounts) Nothing All costs Nothing All costs Nothing Nothing All costs prioritymedicare.com 9

Medigap plans A, C, D, F, G and N (continued) All dollar amounts shown are the 2017 Original Medicare numbers. The benefits and costs shown below are for plans effective on or after January 1, 2017. Plan A Plan C Plan D Services Original Medicare pays Plan pays You pay Plan pays You pay Plan pays You pay Medicare preventive care First $183 of Medicare approved amounts (Part B deductible 3 )when applicable Nothing Nothing $183 $183 Nothing Nothing $183 Medicare approved amounts (after deductible is met) when applicable 80% 20% Nothing 20% Nothing 20% Nothing Blood First 3 pints Nothing 3 pints Nothing 3 pints Nothing 3 pints Nothing Next $183 of Medicare approved amounts (Part B deductible 3 ) Nothing Nothing $183 $183 Nothing Nothing $183 Remainder of Medicare approved amounts (after deductible is met) 80% 20% Nothing 20% Nothing 20% Nothing Clinical laboratory services Tests for diagnostic services 100% Nothing Parts A & B Home health care Medicare approved services Medically necessary skilled care services and medical supplies 100% Nothing Durable medical equipment first $183 of Medicare approved amounts (Part B Nothing Nothing $183 $183 Nothing Nothing $183 deductible 3 ) Remainder of Medicare-approved amounts for durable medical equipment (after deductible is met) 80% 20% Nothing 20% Nothing 20% Nothing Other Benefits Services not covered by Medicare Foreign travel Emergency care services beginning during the first 60 days of each trip outside the U.S. $250 Foreign travel deductible that must be met once each calendar year Nothing Nothing All costs Nothing $250 Nothing $250 Remainder of charges after the foreign travel deductible is met up to a lifetime maximum of $50,000 5 Nothing Nothing All costs 80% 20% 80% 20% 10 Call us toll-free 866.562.5921, seven days a week from 8 a.m. 8 p.m. TTY users should call 711.

Plan F Plan G Plan N Services Original Medicare pays Plan pays You pay Plan pays You pay Plan pays You pay Medicare preventive care First $183 of Medicare approved amounts (Part B deductible 3 )when applicable Nothing $183 Nothing Nothing $183 Nothing $183 Medicare approved amounts (after deductible is met) when applicable 80% 20% Nothing 20% Nothing 20% Nothing Blood First 3 pints Nothing 3 pints Nothing 3 pints Nothing 3 pints Nothing Next $183 of Medicare approved amounts (Part B deductible 3 ) Nothing $183 Nothing Nothing $183 Nothing $183 Remainder of Medicare approved amounts (after deductible is met) 80% 20% Nothing 20% Nothing 20% Nothing Clinical laboratory services Tests for diagnostic services 100% Nothing Parts A & B Home health care Medicare approved services Medically necessary skilled care services and medical supplies 100% Nothing Durable medical equipment first $183 of Medicare approved amounts (Part B Nothing $183 Nothing Nothing $183 Nothing $183 deductible 3 ) Remainder of Medicare-approved amounts for durable medical equipment (after deductible is met) 80% 20% Nothing 20% Nothing 20% Nothing Other Benefits Services not covered by Medicare Foreign travel Emergency care services beginning during the first 60 days of each trip outside the U.S. $250 Foreign travel deductible that must be met once each calendar year Nothing Nothing $250 Nothing $250 Nothing $250 Remainder of charges after the foreign travel deductible is met up to a lifetime maximum of $50,000 5 Nothing 80% 20% 80% 20% 80% 20% prioritymedicare.com 11

1 A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. 2 NOTICE: When your Medicare Part A hospital benefits are exhausted, Priority Health stands in the place of Medicare and pays whatever amount Medicare would have paid for up to an additional 365 days. During this time the hospital can t bill you for the balance based on any difference between its billed charges and the amount Medicare would have paid. 3 The Part B deductible needs to be met only once each calendar year (January 1 December 31). Once you have been billed $183 of Medicareapproved amounts for covered services (which are noted with a 1 ), your Part B deductible will have been met for the calendar year. 4 Emergency visit copay waived and visit covered as a Part A expense if you are admitted to any hospital. Learning more about your choices You can learn more about Priority Health Medigap plans on the phone, online or in person. Ask a question, research your options or attend a Medicare Explained meeting. Call our Medigap experts Get one-on-one help when you call 866.562.5921, seven days a week. TTY users should call 711. 5 Member pays all amounts over $50,000. Go online Visit prioritymedicare.com to view your options. Attend a free Medicare Explained meeting Call us at the number listed at the bottom of this page or go online to find dates and locations near you. 12 Call us toll-free 866.562.5921, seven days a week from 8 a.m. 8 p.m. TTY users should call 711.

Understanding your premiums Use the following charts to determine your Priority Health Medigap plan premium, which is effective as of April 1, 2017. For Priority Health Medigap plans, certain factors may affect your monthly premium. At the time of application, we base our premiums on the county you live in, as well as your age, gender, health status, use of tobacco products and eligibility for open enrollment or a guaranteed issue right. Once you re a Priority Health Medigap member, your premium amount is guaranteed for 12 months. You will receive one premium adjustment annually on the anniversary of your effective date. This will include an age adjustment which is an increase based on being one year older. It will also include any potential premium changes (increase or decrease). We may change the plan premiums each year but only if we change the premium for all members in the same plan (This premium change is subject to state approval). Your premium could also change if you move to a different area. The preferred premium always applies if you are in your open enrollment period or if you have a guaranteed issue right. Your open enrollment period starts on the first day of the month in which you re both 65 and enrolled in Medicare Part B. In most cases, you have a guaranteed issue right when you have other health coverage that changes in some way, for example, if you lose your retiree coverage through your employer. This premium may also apply if you meet certain medical criteria. A tier one or tier two premium may apply if you are no longer in your open enrollment period and/or do not have a guaranteed issue right. These premiums are based on your age, area you live in, health status and whether or not you use tobacco products. Note: If you re under age 65 and meet the eligibility requirements you may be eligible to enroll in Plan A or Plan C. Call us to learn more at 866.562.5921. TTY users should call 711. After you become a member you may continue your coverage if you permanently move outside the State of Michigan. You must reside in Michigan for at least six months of every year to be considered a resident. If you reside in Michigan for less than six months, we will consider you to have permanently moved out of the state. If you remain living in the United States or one of its territories, you may continue your coverage provided all other eligibility requirements continue to be satisfied. After you move, your premium will change to the Area 2 premium. If you move outside of the United States or its territories your Priority Health Medigap plan will be terminated. The State of Michigan requires all Medigap members in Michigan, no matter what insurer you have, to pay a fee called the Health Insurance Claims Assessment (HICA). It has been effective since January 1, 2012. You ll see this tax reflected on your invoice. It is in addition to your monthly premium amount and is factored as a percentage of your premium. The State of Michigan changes the percentage each year. prioritymedicare.com 13

Area 1 Counties: Allegan, Barry, Berrien, Branch, Calhoun, Cass, Ionia, Kalamazoo, Kent, Lake, Mason, Mecosta, Montcalm, Muskegon, Newaygo, Oceana, Osceola, Ottawa, Saint Joseph, Van Buren. Plan A Plan C Plan D Attained age Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female <65 $213 $199 $225 $210 $322 $301 $361 $338 $397 $371 $583 $544 65 $95 $89 $101 $94 $144 $135 $162 $151 $178 $167 $261 $244 $144 $135 $153 $143 $218 $204 66 $99 $92 $105 $97 $150 $139 $168 $156 $185 $172 $272 $252 $150 $139 $159 $147 $227 $210 67 $104 $96 $110 $101 $158 $145 $177 $162 $195 $179 $286 $262 $158 $145 $167 $153 $239 $219 68 $109 $99 $115 $105 $165 $150 $186 $169 $204 $185 $299 $272 $165 $150 $175 $159 $250 $227 69 $114 $103 $121 $109 $173 $156 $194 $175 $214 $192 $313 $282 $173 $156 $183 $165 $262 $236 70 $119 $107 $126 $113 $181 $161 $203 $181 $223 $199 $327 $292 $181 $161 $191 $170 $273 $244 71 $124 $110 $132 $116 $188 $167 $211 $187 $233 $206 $341 $302 $188 $167 $199 $176 $285 $252 72 $130 $114 $137 $120 $196 $172 $220 $193 $242 $213 $355 $312 $196 $172 $207 $182 $297 $261 73 $134 $118 $142 $124 $203 $178 $228 $200 $251 $220 $368 $323 $204 $178 $215 $188 $308 $270 74 $139 $122 $147 $129 $211 $184 $237 $207 $260 $227 $382 $333 $211 $184 $223 $195 $319 $279 75 $144 $126 $152 $133 $218 $190 $245 $213 $269 $235 $395 $344 $218 $190 $231 $201 $330 $288 76 $149 $130 $158 $137 $226 $196 $253 $220 $279 $242 $409 $355 $226 $196 $239 $207 $342 $297 77 $154 $134 $163 $141 $233 $202 $262 $227 $288 $249 $422 $366 $233 $202 $246 $214 $353 $306 78 $158 $137 $167 $144 $239 $207 $269 $232 $295 $255 $433 $374 $239 $207 $253 $218 $362 $313 79 $162 $140 $171 $148 $245 $211 $275 $237 $303 $261 $444 $383 $246 $211 $259 $223 $371 $320 80 $166 $143 $176 $151 $252 $216 $282 $243 $311 $267 $456 $391 $252 $216 $266 $228 $381 $327 81 $170 $146 $180 $154 $258 $221 $289 $248 $318 $273 $467 $400 $258 $221 $273 $233 $390 $334 82 $174 $149 $184 $157 $264 $225 $296 $253 $326 $278 $478 $408 $264 $225 $279 $238 $400 $341 83 $180 $153 $190 $162 $272 $231 $305 $260 $336 $286 $492 $419 $272 $232 $287 $245 $411 $350 84 $185 $157 $195 $166 $280 $238 $314 $267 $345 $293 $506 $430 $280 $238 $296 $251 $423 $360 85+ $190 $161 $201 $170 $287 $244 $323 $273 $355 $301 $520 $441 $288 $244 $304 $258 $435 $369 Claims tax is not reflected in the premium amounts shown in this booklet and will be added to your monthly bill. 14 Call us toll-free 866.562.5921, seven days a week from 8 a.m. 8 p.m. TTY users should call 711.

Plan F Plan G Plan N Attained age Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female <65 65 $167 $156 $176 $165 $252 $236 $148 $139 $157 $147 $225 $210 $117 $109 $123 $115 $177 $165 66 $173 $160 $183 $170 $262 $243 $154 $143 $163 $151 $234 $216 $121 $112 $128 $119 $184 $170 67 $182 $167 $192 $176 $275 $252 $162 $149 $171 $157 $245 $225 $128 $117 $135 $124 $193 $177 68 $191 $173 $202 $183 $289 $262 $170 $154 $180 $163 $257 $234 $134 $121 $141 $128 $202 $184 69 $200 $180 $211 $190 $302 $272 $178 $160 $188 $169 $269 $242 $140 $126 $148 $133 $212 $190 70 $209 $186 $220 $197 $316 $282 $186 $166 $196 $175 $281 $251 $146 $130 $154 $138 $221 $197 71 $217 $193 $230 $203 $329 $291 $194 $172 $205 $181 $293 $260 $152 $135 $161 $143 $230 $204 72 $226 $199 $239 $210 $342 $301 $202 $177 $213 $187 $305 $268 $159 $139 $168 $147 $240 $211 73 $235 $206 $248 $217 $355 $311 $209 $183 $221 $194 $317 $277 $165 $144 $174 $152 $249 $218 74 $243 $213 $257 $225 $368 $322 $217 $189 $229 $200 $328 $287 $171 $149 $180 $157 $258 $225 75 $252 $220 $266 $232 $381 $332 $225 $196 $237 $207 $340 $296 $177 $154 $186 $162 $267 $233 76 $261 $226 $275 $239 $394 $342 $232 $202 $245 $213 $351 $305 $182 $159 $193 $168 $276 $240 77 $269 $233 $284 $246 $407 $353 $240 $208 $253 $220 $363 $314 $188 $163 $199 $173 $285 $247 78 $276 $239 $292 $252 $418 $361 $246 $213 $260 $225 $372 $322 $193 $167 $204 $177 $293 $253 79 $283 $244 $299 $258 $429 $369 $252 $217 $267 $230 $382 $329 $198 $171 $210 $181 $300 $259 80 $290 $249 $307 $264 $439 $377 $259 $222 $274 $235 $392 $336 $204 $175 $215 $185 $308 $264 81 $298 $255 $314 $269 $450 $385 $265 $227 $280 $240 $401 $344 $209 $179 $220 $189 $315 $270 82 $305 $260 $322 $275 $461 $394 $272 $232 $287 $245 $411 $351 $214 $182 $226 $193 $323 $276 83 $314 $267 $332 $282 $475 $404 $280 $238 $295 $252 $423 $360 $220 $187 $232 $198 $333 $283 84 $323 $274 $341 $290 $488 $415 $288 $244 $304 $258 $435 $370 $226 $192 $239 $203 $342 $291 85+ $332 $281 $351 $297 $502 $426 $296 $251 $312 $265 $447 $379 $233 $197 $246 $208 $352 $298 prioritymedicare.com 15

Area 2 Counties: Arenac, Bay, Clare, Clinton, Eaton, Genesee, Gladwin, Gratiot, Hillsdale, Huron, Ingham, Isabella, Jackson, Lapeer, Lenawee, Livingston, Macomb, Midland, Monroe, Oakland, Saginaw, Sanilac, Shiawassee, St. Clair, Tuscola, Washtenaw, Wayne, and outside the state of Michigan. Plan A Plan C Plan D Attained age Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female <65 $207 $193 $219 $204 $313 $292 $354 $331 $390 $364 $572 $534 65 $93 $87 $98 $92 $140 $131 $159 $149 $175 $163 $256 $240 $140 $131 $148 $139 $212 $199 66 $96 $89 $102 $94 $146 $135 $165 $153 $182 $168 $267 $247 $146 $135 $154 $143 $221 $205 67 $101 $93 $107 $98 $153 $141 $174 $159 $191 $175 $280 $257 $153 $141 $162 $149 $232 $213 68 $106 $97 $112 $102 $161 $146 $182 $165 $200 $182 $294 $267 $161 $146 $170 $154 $243 $221 69 $111 $100 $118 $106 $168 $151 $191 $171 $210 $189 $307 $277 $168 $151 $178 $160 $255 $229 70 $116 $104 $123 $110 $176 $157 $199 $178 $219 $195 $321 $286 $176 $157 $186 $166 $266 $237 71 $121 $107 $128 $113 $183 $162 $207 $184 $228 $202 $335 $296 $183 $162 $194 $171 $277 $245 72 $126 $111 $133 $117 $191 $168 $216 $190 $237 $209 $348 $306 $191 $168 $202 $177 $289 $254 73 $131 $115 $138 $121 $198 $173 $224 $196 $246 $216 $361 $317 $198 $173 $209 $183 $299 $262 74 $136 $118 $143 $125 $205 $179 $232 $203 $255 $223 $375 $327 $205 $179 $217 $189 $310 $271 75 $140 $122 $148 $129 $212 $185 $240 $209 $264 $230 $388 $338 $212 $185 $224 $195 $321 $280 76 $145 $126 $153 $133 $219 $191 $249 $216 $273 $238 $401 $348 $220 $191 $232 $202 $332 $289 77 $150 $130 $158 $137 $227 $196 $257 $222 $282 $245 $414 $359 $227 $197 $240 $208 $343 $297 78 $154 $133 $163 $140 $233 $201 $263 $228 $290 $250 $425 $367 $233 $201 $246 $213 $352 $304 79 $158 $136 $167 $144 $239 $206 $270 $233 $297 $256 $436 $375 $239 $206 $252 $217 $361 $311 80 $162 $139 $171 $147 $245 $210 $277 $238 $305 $262 $447 $384 $245 $210 $259 $222 $370 $318 81 $166 $142 $175 $150 $251 $215 $284 $243 $312 $267 $458 $392 $251 $215 $265 $227 $380 $325 82 $170 $145 $179 $153 $257 $219 $291 $248 $320 $273 $469 $400 $257 $219 $271 $232 $389 $332 83 $175 $149 $185 $157 $264 $225 $299 $255 $329 $280 $483 $411 $265 $225 $279 $238 $400 $341 84 $180 $153 $190 $161 $272 $231 $308 $262 $339 $288 $497 $422 $272 $231 $288 $244 $412 $350 85+ $185 $157 $195 $165 $280 $237 $317 $268 $348 $295 $511 $433 $280 $237 $296 $251 $423 $359 Claims tax is not reflected in the premium amounts shown in this booklet and will be added to your monthly bill. 16 Call us toll-free 866.562.5921, seven days a week from 8 a.m. 8 p.m. TTY users should call 711.

Plan F Plan G Plan N Attained age Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female <65 65 $162 $151 $171 $160 $245 $229 $144 $135 $153 $143 $218 $204 $114 $106 $120 $112 $172 $160 66 $168 $156 $178 $165 $255 $236 $150 $139 $159 $147 $227 $210 $118 $109 $125 $116 $179 $165 67 $177 $162 $187 $172 $268 $246 $158 $145 $167 $153 $239 $219 $124 $114 $131 $120 $188 $172 68 $186 $169 $196 $178 $281 $255 $165 $150 $175 $159 $250 $227 $130 $118 $137 $125 $197 $179 69 $194 $175 $205 $185 $294 $264 $173 $156 $183 $165 $262 $236 $136 $122 $144 $129 $206 $185 70 $203 $181 $214 $191 $307 $274 $181 $161 $191 $170 $274 $244 $142 $127 $150 $134 $215 $192 71 $212 $187 $223 $198 $320 $283 $188 $167 $199 $176 $285 $252 $148 $131 $157 $139 $224 $198 72 $220 $194 $233 $204 $333 $293 $196 $172 $207 $182 $297 $261 $154 $136 $163 $143 $233 $205 73 $228 $200 $241 $212 $346 $303 $204 $178 $215 $188 $308 $270 $160 $140 $169 $148 $242 $212 74 $237 $207 $250 $219 $358 $313 $211 $184 $223 $195 $319 $279 $166 $145 $175 $153 $251 $219 75 $245 $214 $259 $226 $371 $323 $218 $190 $231 $201 $330 $288 $172 $150 $181 $158 $260 $226 76 $253 $220 $268 $233 $383 $333 $226 $196 $239 $207 $342 $297 $178 $154 $188 $163 $269 $233 77 $262 $227 $277 $240 $396 $343 $233 $202 $246 $214 $353 $306 $183 $159 $194 $168 $277 $240 78 $269 $232 $284 $245 $406 $351 $239 $207 $253 $219 $362 $313 $188 $163 $199 $172 $285 $246 79 $276 $237 $291 $251 $417 $359 $246 $212 $260 $223 $372 $320 $193 $166 $204 $176 $292 $252 80 $283 $243 $299 $256 $427 $367 $252 $216 $266 $228 $381 $327 $198 $170 $209 $180 $299 $257 81 $290 $248 $306 $262 $438 $375 $258 $221 $273 $233 $390 $334 $203 $174 $214 $183 $307 $263 82 $296 $253 $313 $267 $448 $383 $264 $226 $279 $238 $400 $341 $208 $177 $219 $187 $314 $268 83 $305 $260 $323 $275 $462 $393 $272 $232 $287 $245 $412 $350 $214 $182 $226 $192 $323 $275 84 $314 $267 $332 $282 $475 $404 $280 $238 $296 $251 $423 $360 $220 $187 $232 $197 $333 $283 85+ $323 $274 $341 $289 $488 $414 $288 $244 $304 $258 $435 $369 $226 $192 $239 $203 $342 $290 prioritymedicare.com 17

Area 3 Counties: Alcona, Alger, Alpena, Antrim, Baraga, Benzie, Charlevoix, Cheboygan, Chippewa, Crawford, Delta, Dickinson, Emmet, Gogebic, Grand Traverse, Houghton, Iosco, Iron, Kalkaska, Keweenaw, Leelanau, Luce, Mackinac, Manistee, Marquette, Menominee, Missaukee, Montmorency, Ogemaw, Ontonagon, Oscoda, Otsego, Presque Isle, Roscommon, Schoolcraft, Wexford. Plan A Plan C Plan D Attained age Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female <65 $209 $196 $221 $207 $316 $296 $340 $318 $374 $350 $549 $513 65 $94 $88 $99 $93 $142 $133 $153 $143 $168 $157 $246 $230 $142 $133 $150 $140 $215 $201 66 $98 $90 $103 $96 $148 $137 $159 $147 $175 $162 $256 $237 $148 $137 $156 $145 $223 $207 67 $103 $94 $108 $99 $155 $142 $167 $153 $183 $168 $269 $247 $155 $142 $164 $150 $235 $215 68 $108 $98 $114 $103 $163 $148 $175 $159 $192 $175 $282 $256 $163 $148 $172 $156 $246 $224 69 $113 $101 $119 $107 $170 $153 $183 $165 $201 $181 $295 $266 $170 $153 $180 $162 $258 $232 70 $117 $105 $124 $111 $178 $159 $191 $170 $210 $188 $308 $275 $178 $159 $188 $168 $269 $240 71 $122 $108 $129 $115 $185 $164 $199 $176 $219 $194 $321 $284 $185 $164 $196 $173 $280 $248 72 $127 $112 $135 $118 $193 $169 $207 $182 $228 $200 $334 $294 $193 $170 $204 $179 $292 $257 73 $132 $116 $140 $122 $200 $175 $215 $189 $237 $207 $347 $304 $200 $175 $212 $185 $303 $265 74 $137 $120 $145 $127 $207 $181 $223 $195 $245 $214 $360 $314 $207 $181 $219 $192 $314 $274 75 $142 $124 $150 $131 $215 $187 $231 $201 $254 $221 $372 $324 $215 $187 $227 $198 $325 $283 76 $147 $127 $155 $135 $222 $193 $239 $207 $262 $228 $385 $334 $222 $193 $235 $204 $336 $292 77 $152 $131 $160 $139 $229 $199 $246 $214 $271 $235 $398 $345 $229 $199 $242 $210 $347 $301 78 $156 $134 $164 $142 $235 $203 $253 $219 $278 $240 $408 $353 $235 $203 $249 $215 $356 $308 79 $160 $137 $169 $145 $241 $208 $260 $224 $286 $246 $419 $361 $242 $208 $255 $220 $365 $315 80 $164 $140 $173 $148 $247 $212 $266 $228 $293 $251 $429 $368 $248 $213 $262 $225 $375 $322 81 $168 $144 $177 $152 $254 $217 $273 $233 $300 $257 $440 $376 $254 $217 $268 $230 $384 $329 82 $172 $147 $181 $155 $260 $222 $279 $238 $307 $262 $450 $384 $260 $222 $275 $234 $393 $336 83 $177 $151 $187 $159 $267 $228 $287 $245 $316 $269 $464 $395 $268 $228 $283 $241 $405 $345 84 $182 $154 $192 $163 $275 $234 $296 $251 $325 $276 $477 $405 $275 $234 $291 $247 $416 $354 85+ $187 $158 $198 $167 $283 $240 $304 $258 $334 $283 $490 $416 $283 $240 $299 $253 $428 $363 Claims tax is not reflected in the premium amounts shown in this booklet and will be added to your monthly bill. 18 Call us toll-free 866.562.5921, seven days a week from 8 a.m. 8 p.m. TTY users should call 711.

Plan F Plan G Plan N Attained age Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female <65 65 $164 $153 $173 $162 $248 $232 $146 $136 $154 $144 $221 $206 $115 $107 $121 $113 $174 $162 66 $170 $158 $180 $167 $258 $239 $152 $141 $160 $149 $230 $213 $119 $111 $126 $117 $181 $167 67 $179 $164 $189 $173 $271 $248 $160 $146 $169 $155 $241 $221 $125 $115 $133 $122 $190 $174 68 $188 $170 $198 $180 $284 $258 $167 $152 $177 $161 $253 $230 $132 $119 $139 $126 $199 $181 69 $197 $177 $208 $187 $297 $267 $175 $158 $185 $166 $265 $238 $138 $124 $145 $131 $208 $187 70 $205 $183 $217 $193 $310 $277 $183 $163 $193 $172 $277 $247 $144 $128 $152 $136 $217 $194 71 $214 $189 $226 $200 $324 $287 $191 $169 $201 $178 $288 $255 $150 $133 $158 $140 $227 $201 72 $223 $196 $235 $207 $337 $296 $198 $174 $210 $184 $300 $264 $156 $137 $165 $145 $236 $207 73 $231 $202 $244 $214 $350 $306 $206 $180 $218 $191 $311 $273 $162 $142 $171 $150 $245 $215 74 $239 $209 $253 $221 $362 $316 $213 $186 $225 $197 $323 $282 $168 $147 $177 $155 $254 $222 75 $248 $216 $262 $228 $375 $327 $221 $192 $233 $203 $334 $291 $174 $151 $183 $160 $263 $229 76 $256 $223 $271 $235 $388 $337 $228 $198 $241 $210 $345 $300 $180 $156 $190 $165 $272 $236 77 $265 $229 $280 $242 $400 $347 $236 $204 $249 $216 $357 $309 $185 $161 $196 $170 $281 $243 78 $272 $235 $287 $248 $411 $355 $242 $209 $256 $221 $366 $316 $190 $164 $201 $174 $288 $249 79 $279 $240 $295 $254 $422 $363 $248 $214 $262 $226 $376 $324 $195 $168 $206 $178 $295 $254 80 $286 $245 $302 $259 $432 $371 $255 $219 $269 $231 $385 $331 $200 $172 $212 $182 $303 $260 81 $293 $251 $309 $265 $443 $379 $261 $223 $276 $236 $395 $338 $205 $176 $217 $186 $310 $266 82 $300 $256 $317 $270 $454 $387 $267 $228 $282 $241 $404 $345 $210 $179 $222 $189 $318 $271 83 $309 $263 $326 $278 $467 $398 $275 $234 $291 $248 $416 $354 $216 $184 $229 $195 $327 $279 84 $318 $270 $336 $285 $480 $408 $283 $240 $299 $254 $428 $364 $223 $189 $235 $200 $337 $286 85+ $327 $277 $345 $292 $494 $419 $291 $247 $307 $261 $440 $373 $229 $194 $242 $205 $346 $293 prioritymedicare.com 19

How to apply To apply for any of our Priority Health Medigap plans, You must be enrolled in Medicare Part A and Part B. Once you ve chosen a plan, there are three ways to apply: 1 2 3 Online Go to prioritymedicare.com and follow the directions for completing and submitting the application. Call Contact one of our Medicare experts at 866.562.5921, seven days a week from 8 a.m. 8 p.m. (TTY 711). By mail Fill out the application included in this packet. After you complete it, mail it back to us in the enclosed self-addressed envelope. If you don t have the envelope, you can mail it to: Priority Health Enrollment Department, MS1175 1231 E. Beltline, NE Grand Rapids, MI 49525 Note: Be detailed and complete when applying for coverage. When you fill out your application, be sure to answer all questions truthfully and completely. Priority Health may cancel your plan and refuse to pay any claims if you leave out information or falsify important information. Review your application carefully before you sign it to be sure that all information has been recorded properly. 20 Call us toll-free 866.562.5921, seven days a week from 8 a.m. 8 p.m. TTY users should call 711.

Important information Eligibility At the time of enrollment you must be: 65 or older* Enrolled in Medicare Parts A and B A permanent resident of the State of Michigan (physically residing there six months of every year). Replacing your current coverage If you are replacing your current health insurance policy with a Priority Health Medigap plan, do not cancel your current insurance right away. Wait until you have received your new Medigap certificate and are sure you want to keep it. Are you eligible for the Michigan Medigap subsidy? If you have or enroll in a Medigap plan, you may be eligible to receive the Michigan Medigap Subsidy. If you qualify, you will pay less for your Medigap coverage. The program pays part of your premium (monthly cost) and you pay the rest. Learn more and apply for a subsidy at MichiganMedigapSubsidy.com It s important for you to understand your plan You can use this outline of coverage to compare benefits and premiums among different policies, certificates and contracts. Please keep in mind that this is only an outline of the most important features of the plans. The certificate is your insurance contract. Be sure to read the certificate itself so you understand all of your rights and duties, and you understand the rights and duties of your health plan. If you change your mind We want you to be satisfied with your coverage, so please take time to review it carefully. If you are not satisfied with your certificate, you may return it to: Priority Health Enrollment Department, MS 1175 1231 East Beltline NE Grand Rapids, MI 49525 If you send the certificate back to us within 30 days after it comes to you, we will act as though the certificate was never issued, and we will return all of your payments. We can collect from you all costs for covered services that you received and we paid. * If you re under age 65 and meet the eligibility requirements you may be eligible to enroll in Plan A or Plan C. Call us to learn more at 866.562.5921. Notice: Please be aware that this outline of coverage does not include all the details of your Medigap (Medicare Supplement) coverage, and this plan may not fully cover all of your medical costs. Neither Priority Health Medigap plans nor agents authorized to sell Priority Health Medigap plans are connected with or endorsed by the United States government or the federal Medicare program. This outline of coverage does not give all the details of your Medicare coverage. For information about your Part A and Part B coverage, contact your local Social Security Office or consult the Medicare and You handbook for more details. prioritymedicare.com 23

2017 Priority Health DIFS_2802 MG001 9505D-1 06/17